Arab World: Changing Public Health

From Morocco to Syria, the Arab World has made significant progress in the health of its population in the last 20 years, most notably in reducing the prevalence of infectious disease and prenatal and maternal mortality. As seen in the Global Burden of Disease Study of 2010, the prevalence of chronic diseases has increased and has generally become the main contributor to the burden of disease.[i] However, the significant economic and political variance in the region contributes to vastly different changes in the burdens of diseases in its constituent countries over the past two decades. Diseases related to over-nutrition and sedentary lifestyles are most prevalent in the higher-income countries, while under-nutrition, infectious diseases, and poor environmental and sanitary conditions continue to plague the lower-income countries. Going forward, Arab countries must address their public health challenges by strengthening their health systems and improving health education.

The Global Burden of Disease (GBD) Study of 2010 sheds light on the changes in the health of the Arab World from 1990 to 2010.[ii] The study uses DALYs, which are disability-adjusted life years, measuring the number of health years lost to disabilities and deaths, throughout the last two decades. This term is critical in understanding the burden of disease, or the impact of health problems, on a population. Also important is the distinction between communicable and non-communicable diseases: the former are infectious diseases, like malaria, while the latter are chronic diseases that aren’t transmissible, like heart disease. It is useful to group the data into the three World Bank income groupings of the 22 countries in the Arab League in order to consider how health changes and challenges have varied in the different groupings.[iii]

From 1990 to 2010, in high-income Arab countries including Bahrain, Kuwait, Qatar, Saudi Arabia, and the United Arab Emirates, the burden of disease has remained non-communicable and the prevalence of infectious diseases has decreased. Firstly, non-communicable diseases and accidents contributed to a greater percentage of DALYs lost in 2010 than in 1990. For instance, road related injuries increased more than 60%, while major depressive disorders increased 113%, especially affecting women. Together with ischemic heart disease, they make up the top three contributors to DALYs lost. Additionally, the causes of deaths became more non-communicable as well, with deaths due to ischemic heart disease increasing nearly 60% and those attributed to diabetes increasing almost 200%. Simultaneously, DALYs lost to and deaths caused by infectious and neonatal diseases decreased. For instance, pre-term birth complications, the top contributor to DALYs lost in 1990, decreased 43% in prevalence in 2010. Lower respiratory infections and congenital anomalies were also less prevalent. In sum, high-income countries have undergone the epidemiological transition, meaning that their burden of disease is increasingly non-communicable rather than communicable.

Risk factors for death and disability in high-income Arab countries have shifted to become more centered on over-nutrition and sedentary lifestyles. High blood pressure and body mass index (BMI) were among the biggest risk factors for DALYs in both 1990 and 2010. Both factors increased in prevalence in the 20-year period. Other dietary-related risks such as high blood plasma glucose have increased. Additionally, smoking has also increased in prevalence. However, improvements have been made in poor environmental conditions, like household air pollution. Overall, risk factors for disease in high-income Arab countries have become overwhelmingly related to over-nutrition, smoking, and lack of exercise, which contribute to the shift of disease burden to primarily non-communicable diseases.

In the past 30 years, the burden of disease shifted to become more non-communicable and less communicable in middle-income Arab countries as well. This group of countries includes all of North Africa, Iraq, Jordan, Lebanon, and Yemen. Contrary to the high-income countries, these countries suffered in 1990 from a burden of disease that was almost equally infectious and non-communicable. Over twenty years, lost DALYs continued to be a mixture of both types of diseases, with non-communicable diseases increasing in prevalence and dominating the burden of disease. For instance, the prevalence of heart disease and stroke both increased more than 40%. The prevalence of major depressive disorder also increased significantly, especially among women. Infectious diseases saw a decrease in prevalence, even though they still figured heavily into the burden of disease. Lower respiratory infections, diarrheal diseases, and preterm birth complications decreased 50%, 67%, and 21% respectively in 2010. Similarly, the causes of death also reflected the double burden of disease, although infectious and birth-related diseases decreased. Overall, middle-income Arab countries are currently undergoing the epidemiological transition, showing significant improvements in DALYs lost to and deaths caused by communicable disease while simultaneously exhibiting a burden of disease that is more non-communicable.

The risk factors of disease and deaths in middle-income Arab countries have also shifted to over-nutrition and other characteristics of sedentary lifestyles. In 1990, the top risk factors of deaths included diet and lifestyle habits such as smoking and high BMI, but also included environmental factors like ambient particulate matter (PM) pollution. Contrary to the high-income countries, the top risks of DALYs lost were childhood underweight and sub-optimal breastfeeding, with each risk factor affecting more than 5 million individuals. Twenty years later, the risk factors for deaths and DALYs lost were no longer communicable or birth-related but rather included dietary risks, high blood pressure and BMI, and smoking as the top contributors. Overall, middle-income Arab countries are increasingly manifesting risk factors that lead to non-communicable diseases, displaying improvements with regards to prenatal health, sanitation, and access to safe water.

The burden of disease and death in the low-income Arab World, including Somalia, Djibouti, Comoros, and Mauritania, saw increased prevalence of non-communicable disease, although infectious disease is still dominant. In 1990, the top causes of DALYs lost were all communicable, related to birth or under-nutrition. The top causes of death also generally reflected this trend and included respiratory infections, diarrhea, malaria, malnutrition and stroke. Fast-forward twenty years, and the top causes of DALYs are still infectious or birth-related, although significant headway has been made in reducing their prevalence. For instance, protein-energy malnutrition decreased 26%, while diarrheal diseases decreased 34%. Non-communicable diseases are increasingly present in statistics of disease burden, as evidenced by the increase in prevalence of both stroke and ischemic heart disease by more than 25%. Additionally, certain infectious and birth-related diseases have actually begun affecting more of the population, illustrating the battle low-income Arab countries wage against preventable communicable diseases. For instance, the prevalence of malaria and pre-term birth complications both increased about 37% from 1990 to 2010, posing a serious challenge to the health, economy, and development of low-income countries.

From 1990 to 2010, the risk factors for disease and disability in low-income Arab countries continued to reflect the predominantly communicable and prenatal nature of disease, with improvements made in under-nutrition- and sanitation-related factors. The risk factors for DALYs lost have largely remained tied to the environment and under-nutrition, but notably, factors related to over-nutrition, which include dietary risks and high blood pressure, have been introduced into the population. Firstly, the prevalence of childhood underweight and sub-optimal breastfeeding was each reduced by 35% in 2010. Other shifts were seen in sanitation-related risk factors that indicate improvements. For instance, poor sanitation as a risk factor for DALYs decreased over the twenty-year period. Low water quality and poor access, a common risk factor for diseases like malaria and diarrhea, also saw a significant reduction These shifts in risk factors are important because they indicate that low-income Arab countries face a double burden of disease: while risk factors associated with communicable disease remain prevalent, non-communicable risk factors are also increasingly significant.

It is apparent from the GBD data that the prevalence of non-communicable diseases has increased throughout the Arab World. The greatest contributors to DALYs lost and deaths now include heart disease, stroke, major depressive disorder, and diabetes. However, these observations greatly depend on the income of the country. Risk factors that are related to over-nutrition and a sedentary life-style are also increasingly being seen across the region in general, while poor environmental and sanitary conditions overwhelmingly plague low-income countries. Overall, the average life expectancies of both sexes across the Arab World increased from 65 in 1990 to 70.3 in 2010. These changes indicate that in the Arab World, there is an aging population increasingly suffering from chronic diseases.

Improvements are attributed to the increased investment in health and education that these countries have carried out. For instance, in Tunisia, the National Institute of Public Health conducted a series of health reforms beginning in the 1990s that have increased the number of public health centers and physicians and expanded coverage under insurance schemes.[iv] As a result, vast improvements in malnutrition and diarrheal disease rates have been observed in the last two decades. Increased investments in education, especially for women, have contributed to the decrease in maternal and infant mortality in the Arab World.[v] In Egypt, the average number of years of education for women increased from 2.7 years in 1990 to 5.3 years in 2009.[vi] In correlation, diarrheal diseases in Egypt decreased by 84% and preterm birth complications decreased by 39%. In addition, the GBD has noted the cultural importance of child-birth and the strong familial networks of support have contributed to a reduction in maternal and child mortality.

With these improvements come challenges. First, the aging population presents an enormous financial strain to the rest of the population, exacerbated by the fact that Arab countries generally spend little of their GDP on healthcare. For instance, 4.5% of Yemen’s GDP in 2006 was spent on health, while governmental share of total health expenditures were 46%, indicating that the financial burden of paying to ensure good health rested largely on individual and private expenditures.[vii] The high rates of infectious disease in low-income Arab countries pose a significant financial strain and a huge threat to economic and social development. Additionally, the high rates of road-related injuries have come with increasing vehicular use without corresponding improvements in infrastructure. The high prevalence of depressive disorders among women is also a challenge that must be addressed.

Considering the challenges facing the Arab World, there are several priority steps that should be taken. First, governments need to establish or expand health insurance schemes to finance the rising costs of healthcare and increase coverage in order to ultimately improve health outcomes. To that end, there needs to be continued reform of health systems in the region, specifically to train health professionals and improve the content of health services. Facing these challenges will require using more financial resources. In addition, priority should also be given to health education and preventive care. For instance, nutritional education and anti-smoking campaigns could have far-reaching impacts considering the high rates of smoking in the region –as high as 50% among men in some countries – and the high rates of obesity among women, of whom more than 50% are overweight.[viii]

Fortunately, there has been much more attention paid to health in the Arab World in the last two decades. NGOs have partnered with governments and ministries of public health to evaluate opportunities for and challenges to progress. The first Arab public health conference was held in Dubai in 2013 and brought health experts from across the globe to discuss opportunities and challenges that must be addressed. The second conference of the series will be held in 2015, and is devoted to “benchmarking public health interventions.”[ix]

The lessons presented by the GBD study should be therefore used as a roadmap for health progress in the Arab World, to address the challenges of the future. Professor Ali Mokad, Director of Middle Eastern Initiatives at the Institute for Health Metrics and Evaluation, which published the GBD study, said: “We have a long way to go… I want countries to take the data and use it for planning policies and data. We should all share lessons – both success and failures.” Indeed, as the Arab World faces an era of turmoil and change, there is vast opportunity to continue improving the health of its citizens. History has proved as much.